Social isolation is more than just feeling lonely. For many older adults, isolation directly affects their ability to manage healthcare needs, follow treatment plans, and stay engaged with their medical care. When a patient lives alone, lacks caregiver support, or has limited social connections, they may struggle to keep track of appointments, manage medications, or recognize when they need to contact their clinical team.
CMS recognizes social isolation as one of the psychosocial risks that can affect a patient's health. When isolation significantly interferes with a clinician's ability to diagnose or treat a medical condition, Medicare-covered Community Health Integration, or CHI, may be able to help.
How CHI addresses social isolation
If a licensed clinician determines that social isolation significantly limits their ability to diagnose or treat your medical condition, CHI services may include:
- Helping identify relevant community supports and social engagement programs
- Improving communication between the patient and the medical team
- Encouraging appropriate engagement consistent with the care plan
- Helping the patient develop skills to manage appointments and healthcare needs
- Coordinating with caregivers, family members, or community organizations when appropriate
- Following up to track progress and identify ongoing barriers
What CHI does not do
Important: CHI does not guarantee placement in a specific community program, does not provide companionship services directly, and does not guarantee that any particular resource will be available. CHI is a healthcare service that helps you identify and navigate possible community resources connected to your medical care.
Why isolation matters for health
Research has shown that social isolation is associated with higher risks of chronic conditions, cognitive decline, and difficulty managing existing health problems. During a Medicare Annual Wellness Visit, the clinician may assess for loneliness, social isolation, and life satisfaction as part of the psychosocial risk review.
If the clinician identifies isolation as a barrier that interferes with the patient's medical care, they may determine that CHI is medically appropriate. The AWV can serve as the CHI initiating visit when all applicable requirements are met.
Building patient capacity
One of the key goals of CHI is building the patient's capacity to manage their own healthcare. For isolated seniors, this may include:
- Helping the patient develop skills to schedule and manage appointments
- Maintaining an updated provider list
- Keeping track of referrals and follow-up instructions
- Learning to use available healthcare and community systems
- Recognizing when to contact the clinical team
Feeling isolated and struggling to manage your health? Call our team.
Call (800) 303-1766